MOUNT DESERT POLICE DEPARTMENT BAR HARBOR POLICE DEPARTMENT James K. Willis, Chief of Police

BHPD MDPD 37 Firefly Lane 21 Sea Street, P0 Box 248 Bar Harbor, Maine 04609 NE Harbor, ME 04662 Tel: 207-288-3391 Tel: 207-276-5111 [email protected] [email protected]

TO THE RESIDENT APPLICANT:

Please review the copy of the booklet “Laws Relating to Permits to Carry Concealed Handguns.”Please complete and return this entire package with the following items: • Application for a Permit to Carry Concealed Handguns, pp. 1-6 • Authority and Authorization to Release Information forms must BOTH be filled out completely by the applicant whether applying for the first time or renewing. Return these forms with the application to the Bar Harbor Police Department. • Fee of $40.00 for NEW applicants: o If your permit expired over 6 months ago, you are considered a NEW applicant and must pay the $40.00 fee (Make check payable to: Town of Bar Harbor) you are also required to submit your supporting documents again: eg. Birth Certificate (BC), Hand Gun Safety Certificate (HGS) • A fee of $20.00 is required if you are a valid RENEWAL applicant (your permit is NOT more than 6 months expired, you have NOT changed your address more than 30 days prior without noti~ing the Issuing Authority); • A fee of $2.00 is required if you are requesting a DUPLICATE permit, a CHANGE OF ADDRESS or CHANGE OF NAME permit; o If you moved over 30 days prior without notifying us, not only are you a NEW applicant, your current permit is invalid you are prohibited from carrying a concealed handgun; • If you hold a State of Maine issued permit from another Issuing Authority in Maine, include a complete copy of that permit with your application. • If you are or were a member of the Armed Forces of the United States of America, a copy of your DD2 14 serves as proof of knowledge of handgun safety. You must have served long enough to complete basic firearms training. You also may NOT have a Dishonorable discharge from the Service. NEW Applicants: A copy of your Birth Certificate (BC) or INS document. NEW Applicants: A copy of a certificate which has been issued within the past 5 years that shows Proof of Knowledge of Handgun Safety (HGS).

If you have NOT been issued a permit from the Bar Harbor Police Department in the past, we will need your supporting documents even if you are a valid renewal (you have a current, valid permit issued from another Issuing Authority of Maine). SEND YOUR COMPLETED APPLICATION PACKET TO THE BAR HARBOR POLICE DEPARTMENT AT THE ADDRESS SHOWN ABOVE. MAKE CHECK PAYABLE TO: TOWN OF BAR HARBOR

BAR HARBOR POLICE DEPARTMENT FOR OFFICE USE ONLY APPLICATION FOR PERMIT cI~actc#______J~ô:~b

TO CARRY CONCEALED HANDGUN-. RESIDENT LTCENSE#______

Z NEW ($4o Qo) RENEW ($20.00) : DUPLICATE ($2.00) DATE:______

Z CHANGE OF ADDRESS ($2.00): CHANGE OF NAME ($2.00) DATE IF]SSUED:

FULL NAME:

PRIOR LEGAL NAME(S):

ALIASES:

BIRTHDATE: EYE COLOR: HEIGHT: FT IN

BIRTHPLACE: HAIR COLOR: WEIGHT:

CITIZEN: Y N RACE: SEX: M F

EMAIL ADDRESS:

PHONE NUMBERS

CELL: HOME: WORK:

LEGAL MAILING ADDRESS:

LEGAL PHYSICAL ADDRESS:

LIST ALL ADDRESSES YOU HAVE LIVED AT DURING LAST 5 YEARS; INCLUDE MOVE IN AND MOVE OUT DATES; USE ADDITIONAL SHEET OF PAPER IF NEEDED:

MO/YR IN - MO/YR OUT

PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE AND SHOULD NOT BE USED AG FORM IR REVISED 8/31/2015 Applicant Initials ______Page lof 6 LIST OF PREVIOUSLY ISSUED PERMITS TO CARRY CONCEALED HANDGUNS OR OTHER CONCEALED WEAPONS BY ANY ISSUING AUTHORITY IN MAINE OR ANY OTHER JURISDICTION. For each permit previously issued, please identify the issuing authority (e.g. Massachusetts State Police; Portland P.D.; Town of Shapleigh, Selectmen) and the date the permit was issued.

LIST OF PREVIOUS REFUSALS TO ISSUE PERMIT TO CARRY CONCEALED HANDGUNS OR OTHER CONCEALED WEAPONS BY ANY ISSUING AUTHORITY IN MAINE OR IN ANY OTHER JURISDICTION. For each refusal of a permit, please identify the agency that refused to issue the permit, and the date of refusal. (Include Explanations)

LIST OF PREVIOUS REVOCATIONS OR SUSPENSIONS OF HANDGUNS PERMITS OR PERMITS TO CARRY CONCEALED HANDGUNS OR OTHER CONCEALED WEAPONS BY ANY ISSUING AUTHORITY IN MAINE OR IN ANY OTHER JURISDICTION. For each revocation, please identify the agency or authority that revoked the permit and the date it was revoked or suspended. (Include Explanations)

PREVIOUS VERSIONS OFTHIS FORM ARE OBSOLETE AND SHOULD NOT BE USED

AG FORM IR REVISED 8/31/2015 Applicant tnitials ______Page 2of6 CIRCLE APPROPRIATE ANSWER AFTER EACH QUESTION. a. Are you less than 18 years of age? YES NO b. Is there a formal charging instrument now pending against you in this state for a crime under the laws of this state that is punishable by imprisonment for a term of year or more? YES NO c. Is there a formal charging instrument now pending against you in any federal court for a crime under the laws of the United States that is punishable by imprisonment for a term exceeding one year? YES NO d. Is there a formal charging instrument now pending against you in another state for a crime that, under the laws of the that state, is punishable by imprisonent for a term exceeding one year? YES NO e. If your answer to question (d) is “yes”, is that charged crime classified under the laws of that state as a misdemeanor punishable by a term of imprisonment of 2 years or less? YES NO f. Is there a formal charging instrument pending against you in another state for a crime punishable in that state by a term of imprisonment of 2 years or less and classified by that state as a misdemeanor, but that is substantially similar to a crime that under the laws of this State is punishable by imprisonment for a term of one year or more? YES NO g. Is there a formal charging instrument now pending against you under the laws of the United States, this State or any other state or the PassamaquoddY Tribe or Penobscot Nation in a proceeding in which the prosecuting authority has pleaded that you committed the crime with the use of a Handgun against a person or with the use of a dangerous weapon as defined in Title 17-A, M.R.S.A. § 2(9) (A)? YES NO h. Is there a formal charging instrument now pending against you in this or any other jurisdiction for a juvenile offense that, if committed by an adult, would be a crime described in question (b), (c), (d) or (I) and involves bodily injury or threatened bodily injury against another person? YES NO i. Is there a formal charging instrument now pending against you in this or any other jurisdiction for a juvenile offense that, if committed by an adult, would be a crime described in question (g)? YES NO j. Is there a formal charging instrument now pending against you in this or any other jurisdiction for a juvenile offense that, if committed by an adult, would be a crime described in question (b), (c), (d) or (f), but does not involve bodily injury or threatened bodily injury against another person? YES NO k. Have you ever been convicted of committing or found not criminally responsible by reason of insanity or mental disease or defect of committing a crime described in question (b), (c), (I’) or (g)? YES NO

I. Have you ever been convicted of committing or found not criminally responsible by reason of insanity or mental disease or defect of committing a crime described in question (d)? YES NO m. If your answer to question (I) is “yes,” was that crime classified under the laws of that state as a misdemeanor punishable by a term of imprisonment of 2 years or less? YES NO

PREVIOUS VERSIONS OFTHIS FORM ARE OBSOLETE AND SHOULD NOT BE USED AG FORM IR REVISED 8/31/2015 Applicant Initials Page 3ofG n. Have you ever been adjudicated as having committed a juvenile offense described in question (h) or (i)? YES NO o. Have you ever been adjudicated as having committed a juvenile offense described in question U)? YES NO p. Are you currently subject to an order of a Maine court or an order of a court of the United States or another state, territory, commonwealth or tribe that restrains you from harassing, stalking or threatening your intimate partner, as defined in 18 United States Code, Section 921(a), or a child of your intimate partner, or from engaging in other conduct that would place

your intimate partner in reasonable fear of bodily injury to that intimate partner or the child? -- YES NO q. Are you a fugitive from justice? YES NO r. Are you a drug abuser, drug addict or drug dependent person? YES NO s. Do you have a mental disorder that causes you to be potentially dangerous to yourself or others? YES NO t. Have you been adjudicated to be an incapacitated person pursuant to Title 18-A, Article V, Parts 3 and 4, and not had that designation removed by an order under Title 18-A, M.R.S.A. §5-307 (b)? [Termination of incapacity, Probate Code; protection of persons under disability and their property] YES NO u. Have you been dishonorably discharged from the military forces within the past 5 years? YES NO v. Are you an illegal alien? YES NO w. Have you been convicted in a Maine court of a violation of Title 17-A, M.R.S.A. § 1057 [possession of a Handgun in an establishment licensed for on-premises consumption of liquor] within the past five (5) years? YES NO x. Have you been adjudicated in a Maine court within the past five (5) years as having committed a juvenile offense involving conduct that, if committed by an adult, would be a violation of Title 17-A, M.R.S.A. § 1057 [criminal possession of a Handgun in an establishment licensed for on-premises consumption of liquor]? YES NO y. To your knowledge, have you been the subject of an investigation by any law enforcement agency within the past 5 years regarding the alleged abuse by you of family or household members? YES NO z. Have you been convicted in any jurisdiction within the past 5 years of 3 or more crimes punishable by a term of imprisonment of less than one year or of crimes classified under the laws of a state as a misdemeanor and punishable by a term of imprisonment of 2 years or less? YES NO aa. Have you been adjudicated in any jurisdiction within the past 5 years to have committed 3 or more juvenile offenses described in question (o)? YES NO bb. To your knowledge, have you engaged within the past 5 years in reckless or negligent conduct [as defined at 25 M.R.S.A. § 2002(11)] that has been the subject of an investigation by a governmental entity? YES NO

PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE AND SHOULD NOT BE USED

AG FORM IR REVISED 8/3 1/2015 Applicant Initials ______Page 4 of 6 cc. Have you been convicted in a Maine court within the past 5 years of any Title 17-A, chapter 45 drug crime? YES NO dd. Have you been adjudicated in a Maine court within the past 5 years as having committed a juvenile offense involving conduct that, if committed by an adult, would have been a violation of Title 17-A, chapter 45? [Drug offenses] YES NO ee. Have you been adjudged in a Maine court to have committed the civil violation of possession of a useable aimunt of marijuana, butyl nitrite or isobutyl nitrite in violation of Title 22 M.R.S.A. §2383within thepast Syears? YES NO ff. Have you been adjudicated in a Maine court within the past 5 years as having committed the juvenile crime defined in Title 15 M.R.S.A. § 3103 (1) (B) of possession ofa useable amount of marijuana, as provided in Title 22 M.R.S.A. § 2383? YES NO

READ THE FOLLOWING CAREFULLY BEFORE SIGNING APPLICATION

BY AFFIXING YOUR SIGNATURE BELOW AS THE APPLICANT YOU:

A. Certify that the statements you have made on this application and any documents you make a part of this application, are true and correct.

A-i. Certify that you understand that a “yes” answer to question (I) or (o) above is cause for reftisal unless you are authorized to possess a Handgun under Title 15 M.R.S.A. § 393.

A-2. Certify that you understand that a “yes” answer to question (p) is cause for refusal if the order of the court meets the preconditions contained in Title 15, M.R.S.A. § 393 (1) (D). If the order of the court does not meet the preconditions, the conduct underlying the order may be used by the issuing authority, along with other information, in judging good moral character under 25 M.R.S.A. § 2003 (4).

B. Certify that you understand that a “yes” answer to question number (a), (k), (n), or any of the questions numbered (q) through (x) above is cause for refusal.

B-I. Certify that you understand that a “yes” answer to one or more of the questions numbered (b) through U). (m), (y), (z), or (aa) to (if) above will be used by this issuing authority, along with other information, in judging good moral character under Title 25 M.R.S.A. § 2003(4).

C. Certify that you will, that at the request of this issuing authority, take whatever action is required of you by law to allow this issuing authoi-ity to obtain from the Maine Department of Health and Human Services (limited to records of patient committals to Riverview Psychiatric Center and Dorothea Dix Psychiatric Center), the courts, law enforcement agencies, the military, the United States Citizenship and Immigration Services, and any prior issuing authority in this State or any other jurisdiction with which you have been involved, information relevant to the following:

PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE AND SHOULD NOT BE USED AG FORM IR REVISED 8/31/2015 Applicant Initials PageS of 6 (1) The determination as to whether the information supplied on the application or any documents made a part of the application is true and correct; (2) The determination as to whether each of the additional requirements of Title 25 M.R.S.A. § 2003 has been met; (3) The determination as to whether, if you are currently a permit holder, such pern-it must be revoked under Title 25 M.R.S.A. § 2005; and (4) The determination as to whether, if you are otherwise eligible and reapplying following an earlier revocation of a permit, you are eligible to do so under Title 25 M.R.S.A. § 2005 or Title 17-A M.R.S.A. § 1057.

D. Certify that you understand that if fingerprints are required by this issuing authority in order to resolve any questions as to your identity, you will submit to being fingerprinted. B. Certify that you understand that if a photograph is an integral part of the pemiit to carry concealed Handguns adopted by this issuing authority, you will submit to being photographed for that purpose.

F. Certify that you understand that you must demonstrate to this issuing authority a knowledge of handgun safety as required by Title 25 M.R.S.A. § 2003 (1) (B) (5), unless you demonstrate that you are exempted under that same statute. G. Certify that you have received a copy of the pamphlet entitled “LAWS RELATING TO PERMiTS TO CARRY CONCEALED HANDGUNS” (2014 edition). H. I understand that any false statements I make in this application or documents I make a part of this application may result in criminal prosecution pursuant to 25 M.R.S.A. § 2004 (I) and/or 17-A M.R.S.A. § 453, unsworn falsification.

Your Signature as Applicant Date

ALL QUESTIONS MUST BE ANSWERED COMPLETELY AND THE APPLICATION FEE ($40 FOR ORIGINAL APPLICATION, $20 FOR RENEWAL APPLICATION, OR $2.00 FOR CHANGE OF ADDRESS, DUPLICATE OR CHANGE OF NAME) MUST ACCOMPANY THIS APPLICATION OR THE APPLICATION WILL BE RETURNED.

PREVIOUS VERSIONS OF THIS FORM ARE OBSOLETE AND SHOULD NOT BE USED

AG FORM 1k REVISED 8/31/2015 Applicant Initials ______Page 6 of 6 AUTHORIZATION TO PSYCHIATRIC FACILITY TO RELEASE INFORMATION FOR THE PURPOSE OF APPLYING FOR A CONCEALED HANI)GUN PERMIT

PRINT LEGIBLY OR TYPE NAME OF APPLICANT: DOB:______

ALIAS ANDIOR PRIOR NAME(S):______

Pursuant to 25 MRS. §2003 (l)(E)(1), I authorize the Riverview Psychiatric Center and the Dorothea Dix Psychiatric Center of the Department of Health and Human Services to disclose any record of whether I have ever been committed to the Riverview Psychiatric Center or the Dorothea Dix Psychiatric Center to the issuing authority:

Issuing Authority (individual) Chief James Willis / Lt. James Pinkliam Issuing Authority (organization) Bar Harbor Police Department Mailing Address 37 Firefly Lane, Bar Harbor, ME 04609 Issuing Authority Fax # (207) 288-2120 Telephone # to verify receipt of fax (~07) 288-3391

I understand that the information requested is protected by law and cannot be released without my written permission, unless otherwise specifically permitted by law. I understand that I have the right to review information and material prior to its release. I understand I have the right to revoke this authorization in writing at any time by contacting the issuing authority identified above. I understand that my refusal to sign this release will cause my application for a concealed handgun permit to be rejected. I understand that if the issuing authority receives an affirmative response to its inquiry, I may be asked to authorize the release of additional information to determine my eligibility for a concealed handgun permit. Information disclosed to the issuing authority pursuant to this release is confidential pursuant to 25 M.R.S. § 2006.

This authorization is effective for six months following the date of my signature.

Applicant Signature Date

Witness Signature Date

APPLICANT: DO NOT SEND THIS FORM TO THE HOSPITAL. YOU MUST RETURN TIllS FORM TO THE ISSUING AUTHORITY IDENTIFIED ABOVE WITH YOUR PERMIT APPLICATION. OR YOUR APPLICATION MAY NOT BE PROCESSED.

ISSUING AUTHORITY: Send completed form (or a copy) to Riverview Psychiatric Center (RPC) AND to Dorothea Dix Psychiatric Center (DDPC) by 2hi~ of the following means:

1. Scan form and send via e-mail to: [email protected] AND DorotheaDixMedicalRecords @maine.~ov OR 2. Faxform to: RPC: (207) 287-7127 AND DDPC: (207) 941-4029 OR 3. Mail the form, with a self-addressed stamped envelope to: Riverview Psychiat4c Center, 250 Arsenal St., Augusta, ME 04330, Attn. Health Information; AND Dorothea Dix Psychiatric Center, P0 Box 926, Bangor, ME 04401, Attn. Medical Records.

NOTICE TO ISSUING AUTHORITY: The RPC and DDPC will respond in the same manner in which you forward this form. However, if you fax the form, you must provide your telephone number so that the institution can veri~’ your receipt of the return fax.

AG Form 6: Revised June 17,2013 All previous versions of this form are obsolete. AUTHORITY TO RELEASE INFORMATION TO THE ISSUING AUTHORITY FOR THE PURPOSE OF EVALUATING INFORMATION SUPPLIED ON MY APPLICATION FOR A CONCEALED HANDGUN PERMIT UNDER 25 M.R.S., CHAPTER 252.

TO ALL LAW ENFORCEMENT AGENCIES, INCLUDING COURTS, BOTH WITHIN AND WITHOUT THE STATE OF MAINE:

I hereby authorize and direct you to release to the issuing authority or its representative any information in your possession or control concerning me pertaining to the following:

(1) conviction data;

(2) any criminal matter in which a formal charging instrument is now pending;

(3) adjudication data relating to any juvenile offenses which involves conduct which, if committed by an adult, would be a crime;

(4) any juvenile matter in which a formal charging instrument is now pending involving any juvenile offense described in (3) above;

(5) fugitive from justice status;

(6) incidents of abuse of family or household members within the past five years;

(7) drug abuse, drug addiction or drug dependency;

(8) adjudication as an incapacitated person;

(9) any mental disorder that causes me to be potentially dangerous to myself or others;

(10) reckless or negligent conduct as defined by 25 M.R.S. § 2002(11) within the past five years;

(11) information of record indicating that I have been convicted of or adjudicated as having committed a violation of Title 17-A, chapter 45 or Title 22, section 2383, or adjudicated as having committed a juvenile crime that is a violation of Title 22, section 2383 or a juvenile crime that would be defined as a criminal violation under Title 17-A, chapter 45 if committed by an adult; and

(12) whether I am currently subject to an order of a Maine court or an order of a court of the United States or another state, territory, commonwealth or tribe that restrains me from harassing, stalking or threatening an intimate partner, as defined in 18 United States Code, Section 921(a), or a child of an intimate partner, or from engaging in other conduct that would place an intimate partner in reasonable fear of bodily injury to that intimate partner or the child.

TO ALL PRIOR ISSUING AUTHORITIES, BOTH WITHIN AND WITHOUT THE STATE OF MAINE:

I hereby authorize and direct you to release to the issuing authority or its representative any information of record in your possession or control concerning me pertaining to any previous refusal to issue or revocation of a permit to carry handguns or firearms, or other weapons.

AG Form 5: Revised 6/17/13 All previous versions of this form are obsolete. Page 1 of 2 TO ALL MILITARY FORCES, BOTH STATE AND FEDERAL:

I hereby authorize and direct you to release to the issuing authority named below or its representative any information in your possession or control concerning me pertaining to a dishonorable discharge from the military forces within the past 5 years.

TO THE UNITED STATES CITIZENSHIP AND IMMIGRATION SERVICES:

I hereby authorize and direct you to release to the issuing authority or its representative any information in your possession or control concerning me pertaining to my status as an illegal alien.

TO ALL ABOVE-ADDRESSED GOVERNMENTAL ENTITIES:

I hereby authorize and direct you to release to the issuing authority named below or its representative any information in your possession or control concerning me pertaining to the following:

(1) my full name; (2) my full current address and address for the prior 5 years; (3) the date and place of my birth and my physical description; (4) my signature.

Should there be any question to the validity of this release, you may contact me at the address and/or the telephone number listed below. DATE:

APPLICANT’S FULL NAME: (Typed or printed) APPLICANT’S FULL NAME: (Signature) DATE OF BIRTH OF APPLICANT:

Mailing Address of Applicant:

Telephone Number of Applicant:

BAR HARBOR POLICE DEPARTMENT CHIEF JAMES WILLIS / LT. JAMES PINKHAM ISSUING AUTHORITY (Organization) ISSUING AUTHORITY REPRESENTATIVE (Name)

INFORMATION OBTAINED PURSUANT TO THIS RELEASE IS CONFIDENTIAL TO THE EXTENT PROVIDED BY 25 M.R.S. § 2006 AND MAY NOT BE MADE AVAILABLE FOR PUBLIC INSPECTION OR COPYING BY THE ISSUING AUTHORITY UNLESS THE CONFIDENTIALITY IS WAWED BY THIS APPLICANT BY WRITTEN NOTICE TO THE ISSUING AUTHORITY.

THIS ORIGINAL RELEASE, AND ANY COPIES, ARE VALID FOR A PERIOD OF SIX MONTHS FROM THE DATE OF SIGNATURE OF THE APPLICANT.

AG Form 5: Revised 6/17/13 All previous versions of this form are obsolete. Page 2 of 2